PROJECT

CLIENT

:
:

CONTRACTOR
:
SUBCONTRACTOR :

WATER FILTRATION PLANT, CNG & AIR COMPRESSOR

PT SUZUKI INDOMOBIL MOTOR

Srl. No. 00___

HITACHI PLANT

CHECK LIST FOR SCAFFOLDING ERECTION

Location of Work:
Drawing Ref.

________________________________________

Spec. Section Ref

Checked By
Contractor

ITEM

Checked By
Consultant

YES
1

Method Statement submitted, approved

Is risk assessement/JHA done and approved

Are workers erecting/dismantling trained and competent

Is a competent supervisor supervising erection/dismantling

Are the workshop drawings approved?

Has all scaffolding material been checked and

REMARKS

NO

defective material sorted out?

6

Are all personnell erecting the scaffold using safety

equipment such as safety helmets and harnesses?

Foundation,ground conditions suitable for erection of

scaffold.

Is the ground level well compacted?

Have all standards been erected on base plates?

10

Are timber sole plates provided to prevent sinking

11

Are all standard fixed in true plumb?

12

Is the bracing between the standards correctly and

rigidly fixed?

13

Have the elevation diagonal bracing's been provided?

14

Are all couplers and jointing pins correctly and rigidly

fixed?

15

Are all boards in the working platform properly

supported max. 1.50m c/c?( Boards to be min 32mm thick)

16

Are handrails and midrails for the working platform provided?

17

Are all boards firmly secured with holding clamps?

18

Has the toe board been provided in the working

platform?

19

Has the scaffold been tied with existing features for

stability?

20

Has safe ladder access been provided?

21

Have warning notices been provided for incomplete

scaffold?

22

Have a standard scaffolding tags provided

COMMENTS:

Subcontractor

Approved

Contactor

Name
Safety Officer

Signature
Date

Site Manager

Safety Officer

Project Manager

Note

1. To be attached to Request for Inspection

PT. TAKASAGO THERMAL ENGINEERING

PROJECT
CLIENT

:
:

HC/FC Project
P&G Indonesia

CONTRACTOR
:
SUBCONTRACTOR :

No. 00___

PT. Takasago Thermal Engineering

CHECK LIST FOR SCAFFOLDING ERECTION

Location of Work:
Drawing Ref.

________________________________________

Spec. Section Ref

Checked By
ITEM

Sub Contractor

Checked By
Contractor

YES
1

Pernyataan metode diajukan, disetujui

Apakah risiko assessement / JSEA dilakukan dan disetujui

Apakah pekerja yang mendirikan / pembongkaran terlatih dan kompeten

Apakah seorang supervisor yang kompeten mengawasi pasang / bongkar

Apakah gambar-gambar Pembuatan disetujui?

Apakah semua bahan perancah diperiksa dan

REMARKS

NO

bahan yang rusak tidak Digunakan?

Apakah semua personnel mendirikan perancah menggunakan PPE

seperti helm pengaman, Harness dan perlengkapan pakaian?

Pondasi, kondisi tanah cocok untuk pendirian scaffold

Apakah permukaan tanah dipadatkan dengan baik?

Apakah semua standar telah didirikan pada pelat dasar?

10

Apakah kayu pelat tunggal disediakan untuk mencegah tenggelam

11

Apakah semua standar tetap dalam benar tegak lurus?

12

Apakah bracing antara standar dengan benar dan

kaku diperbaiki?

13

Apakah bracing diagonal elevasi yang telah disediakan?

14

Apakah semua skrup dan pin jointing benar dan kaku

tetap?

15

Apakah semua papan dalam platform bekerja dengan baik

didukung maks. 1.50cm (Board menjadi min tebal 32mm)

16

Apakah pegangan tangan dan midrails untuk platform kerja ada?

17

Apakah semua papan tegas dijamin dengan memegang klem?

18

Apakah papan kaki telah disediakan dalam bekerja untuk platform

19

Apakah Scaffold telah diikat dengan fitur yang ada untuk

stabilitas?

20

Apakah akses tangga aman telah diberikan?

21

Apakah pemberitahuan peringatan telah disediakan untuk kelengkapan

scaffold?

22

Memiliki tag perancah standar yang disediakan

COMMENTS:

Subcontractor

Approved

Contractor

Name
Safety Officer

Site Manager

Signature
Date
Note

1. To be attached to Request for Inspection

Safety Officer

Construction Manager